Patient Number:
Patient Name:

INSTRUCTIONS: This survey asks for views about your health. This information will help keep track of how you feel and how well you are able to do your usual daily activities. Answer every question marking the answer as indicated. If you are unsure about how to answer a question, please give the best answer you can.

1. In general, would you say your health is:

Excellent Very Good Good Fair Poor

2. Compared to one year ago, how would you rate your health in general at this time?

Much better now than one year ago Somewhat better now than one year ago About the same as one year ago Somewhat worse that one year ago Much worse now than one year ago

3. The following items are about activities you might do during a typical day. Does your health now LIMIT YOU in these activities? If so, how much?

Activities: Yes, limited a lot Yes, limited a little No, not limited at all Vigorous activities, such as running, lifting heavy objects, or participation in strenuous sports Moderate activities, such as moving a table, vacuuming, bowling or golfing Lifting or carrying groceries Climbing several flights of stairs Climbing one flight of stairs Bending, kneeling, or stooping Walking more than a mile Walking several blocks Walking one block Bathing or dressing yourself

4. During the past 30 days, have you had any of the following problems with your work or other regular activities as a result of your physical health?

Activities: Yes No Cut down on the amount of time you spent on work or other activities Accomplished less than you would like Lifting or carrying groceriesc. Were limited in the kind of work or other activities Had difficulty performing the work or other activities (For example – requiring an extra effort)

5. During the past 30 days, have you had any of the following problems with your work or other regular daily activities as result of any emotional problems (such as feeling depressed or anxious)?

Activities: Yes No Cut down on the amount of time you spent on work or other activities Accomplished less than you would like Didn’t do work or other activities as carefully as usual

6. During the past 30 days, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors or groups?

Not at all Slightly Moderately Quite a bit Extremely

7. How much bodily pain have you had during the past 30 days?

None Very mild Mild Moderate Severe Very severe

8. During the past 30 days, how much did pain interfere with your normal work (including both work outside the home and housework)?

Not at all Slightly Moderately Quite a bit Extremely

9. These questions are about how you feel and how things have been with you during the past 30 days. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 30 days:

All of the time Most of the time A good bit of the time Some of the time A little of the time None of the time Did you feel full of pep? Have you been a very nervous person? Have you felt so down in the dumps that nothing could cheer you up? Have you felt calm & peaceful? Did you have a lot of extra energy? Have you felt downhearted and blue? Did you feel worn out? Have you been a happy person? Did you feel tired?

10. During the past 30 days, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives etc.)?

All of the time Most of the time Some of the time A little of the time None of the time

11. How TRUE or FALSE is each of the following statements to you?

Definitely True Mostly True Don’t Know Mostly False Definitely False I seem to get sick easier than other people I am as healthy as anybody I know I expect my health to get worse My health is excellent